Johan Vaninbroukx

A randomized phase II study of drug-eluting beads versus transarterial chemoembolization for unresectable hepatocellular carcinoma.

Background: Transcatheter arterial chemoembolization (TACE) is the standard treatment in selected patients with unresectable hepatocellular carcinoma (HCC). Drug-eluting particles are developed to reduce side effects and improve efficacy. We present safety data of a prospective randomized phase II study with doxorubicin-eluting superabsorbent polymer (SAP) microspheres. Material and Methods: We prospectively included 30 HCC patients with different Barcelona Clinic Liver Cancer (BCLC) stages (A = 3, B = 19, C = 8) and randomly assigned them to receive conventional TACE (n = 14) (control group) or doxorubicin-eluting SAP microspheres (n = 16). The doxorubicin plasma level was assessed at different time points, biochemical analysis was performed, and side effects were reported following the Common Toxicity Criteria. Tumor response was assessed at 6 weeks according to the modified Response Evaluation Criteria in Solid Tumors (RECIST) criteria. Results: There was a significantly lower plasma peak concentration (Cmax) of doxorubicin and smaller area under the curve (AUC) with SAP microspheres (mean Cmax 495 ± 293.9 ng/ml, mean AUC 69.7 ± 26.9 ng/ml min) compared to controls (mean Cmax 1,928 ± 560.8 ng/ml, mean AUC 165 ± 32.3 ng/ml/min; both p < 0.001). Furthermore, there were less grade 3 and no grade 4 adverse events in the SAP microsphere group. Tumor response was comparable between the groups. Conclusions: TACE with SAP microspheres leads to low plasma levels of the cytotoxic drug and therefore minimizes toxicity compared to conventional TACE.

Factors influencing technical success and outcome of percutaneous balloon angioplasty in de novo native hemodialysis arteriovenous fistulas

OBJECTIVE To determine predictors of technical success, dysfunction recurrence and patency after percutaneous transluminal angioplasty (PTA) of de novo dysfunctional hemodialysis arteriovenous fistulas (AVFs). METHODS Retrospective analysis of first time PTA of 167 AVF in 162 patients (100 men, 66±13 years). Anatomical (location, length, grade and number of stenoses) and clinical variables (sex, age, prior AVF, diabetes mellitus and AVF age, side and location) were reviewed. RESULTS 217 stenoses or segmental occlusions were treated. Technical success rate (84.4%) was higher in radiocephalic AVF compared to brachial artery-median vein AVF (p=0.030) and was negatively correlated with initial stenosis (p=0.049). Dysfunction recurrence was seen in 52.7% and correlated negatively with technical success (p=0.013) and AVF age (p=0.008). Early dysfunction (within 6 months) was negatively correlated with AVF age (p=0.016) and positively with diabetes (p=0.003). Higher AVF age resulted in higher primary (p=0.005) and secondary patency rates (p=0.037-0.005). CONCLUSIONS Technical success of PTA in hemodialysis AVF is affected by AVF type and initial stenosis and has significant effect on dysfunction recurrence, but not on AVF longevity. Younger AVF has increased risk for (early) recurrent dysfunction and lower patency rates. Patients with diabetes mellitus have higher risk for early dysfunction.

Transcatheter Chemoembolization of Unresectable Hepatocellular Carcinoma: Current Knowledge and Future Directions

Transarterial chemoembolization (TACE) is considered the gold standard for the treatment of unresectable hepatocellular carcinoma (HCC) in patients with a preserved liver function and in the absence of clear extrahepatic tumor spread. This review article deals with the radiological and clinical workup, the interventional technique of chemoembolization for HCC and gives an overview of the common as well as some rare and dramatic complications of TACE. Finally, some new trends and advances in clinical research with regard to the interventional management of HCC are discussed.

Prospective Study Comparing Different Indirect Methods to Measure Portal Pressure

PURPOSE To compare the accuracy of wedged hepatic venous pressure (WHVP) measurement with use of an end-hole catheter or an occlusion-balloon catheter versus direct portal pressure (PP) measurement in patients with cirrhosis with sinusoidal portal hypertension and to investigate the factors that affect the results of these indirect measurements. MATERIALS AND METHODS In a cohort of 174 patients with cirrhosis referred for transjugular intrahepatic portosystemic shunt creation, indirect PP was measured with an end-hole catheter and an occlusion-balloon catheter placed in the right hepatic vein. Direct PP was measured by a pigtail catheter in the main branch of the portal vein. RESULTS PP was more accurately estimated by the occlusion-balloon technique: mean WHVP measurements were 25.5 mm Hg ± 7.9 and 30.6 mm Hg ± 13.9, respectively, for the occlusion-balloon and end-hole catheter techniques, and the direct PP measurement was 25.0 mm Hg ± 7.0. The median absolute differences between direct and the indirect methods were 6.0 mm Hg with the end-hole catheter and 2.0 mm Hg with the occlusion-balloon catheter (P < .0001, signed-rank test). Relative to direct PP measurements, the occlusion-balloon technique overestimated pressures in cases of higher Model for End-Stage Liver Disease (MELD) scores (Spearman ρ = -0.24; P = .0005). CONCLUSIONS Compared with direct PP measurements, agreement was clearly higher for indirect WHVP measurement with occlusion-balloon catheters versus end-hole catheters. However, in patients with a high MELD score, there was an overestimation of PP with the occlusion-balloon method.

Extracranial carotid artery stenting in surgically high-risk patients using the Carotid Wallstent endoprosthesis: midterm clinical and ultrasound follow-up results

AbstractThe purpose of this study was to evaluate the feasibility, safety and midterm outcome of elective implantation of the Carotid Wallstent® in patients considered to be at high surgical risk. In a prospective study, 54 carotid artery stenoses in 51 patients were stented over a 24-month period. Three patients underwent bilateral carotid artery stenting. Institutional inclusion criteria for invasive treatment of carotid occlusive disease (carotid endarterectomy or carotid artery stenting) are patients presenting with a 70% or more symptomatic stenosis and those with an 80% or more asymptomatic stenosis having a life-expectancy of more than 1 year. All patients treated by carotid artery stenting were considered at high risk for carotid endarterectomy because of a hostile neck (17 patients—31.5%) or because of severe comorbidities (37 patients—68.5%). No cerebral protection device was used. Of the 54 lesions, 33 (61.1%) were symptomatic and 21 (38.8%) were asymptomatic. Follow-up was performed by physical examination and by duplex ultrasonography at 1 month, 6 months, 1 year and 2 years after the procedure. All 54 lesions could be stented successfully without periprocedural stroke. Advert events during follow-up (mean 13.9 ± 5.7 months) were non-stroke-related death in 6 patients (11.1%), minor stroke in 4 stented hemispheres (7.4%), transient ipsilateral facial pain in 1 patient (1.8%), infection of the stented surgical patch in 1 patient (1.8%) and asymptomatic instent restenosis in 4 patients (7.4%). The percutaneous implantation of the Carotid Wallstent®, even without cerebral protection device, appears to be a safe procedure with acceptable clinical and ultrasonographic follow-up results in patients at high surgical risk. But some late adverse events such as ipsilateral recurrence of non-disabling (minor) stroke or instent restenosis still remain real challenging problems.

Are TIPS Stent-Grafts a Contraindication for Future Liver Transplantation?

Our purpose was to assess the feasibility of orthotopic liver transplantation (OLT) in patients priorly having undergone transjugular intrahepatic portosystemic shunt (TIPS) with an expanded tetrafluoroethylene (e-PTFE)-covered endoprosthesis. In 48 patients an e- PTFE-covered endoprosthesis was inserted to treat severe complications of portal hypertension. In 36 patients the endoprosthesis was inserted during TIPS creation (de novo TIPS); in the other 12 patients the endoprosthesis was placed to repermeabilize the previously created, but occluded bare stent (revision TIPS). Eight of them (5 de novo and 3 revision cases) later underwent an OLT. The hospital records of these patients were reviewed from initial admission, through TIPS, the pre-OLT period, and OLT to current postoperative status. Five de novo and 3 revision cases underwent OLT 4–279 days (mean delay: 80.8 days) after TIPS procedure. All OLT’s were performed under veno-venous bypass surgery. De visu surgical inspection confirmed correct positioning of the fully patent stent graft, starting in the portal vein and ending at the junction of the hepatic vein to the inferior caval vein. No surgical difficulty was observed during proximal or distal clamping or during resection of the diseased liver. Correctly positioned e-PTFE-covered nitinol endoprostheses do not interfere with a later OLT and may not be considered as a contraindication in patients who need a TIPS as a bridge to OLT.

Transcatheter arterial embolization for iatrogenic hemobilia is a safe and effective procedure: case series and review of the literature.

Objective Hemobilia is an uncommon cause of gastrointestinal bleeding. The etiology is diverse, but most often, it is iatrogenic. The present study aims to reassess the clinical picture and the treatment of choice. Methods We describe a case series from a single center of patients who presented with nontraumatic iatrogenic hemobilia. Results Over a period of 8 years, hemobilia occurred in 12 patients: following liver biopsy in six patients and after endoscopic biliary interventions in four patients, with a respective prevalence of 0.1 and 0.04%. The clinical presentation was characterized by an upper gastrointestinal bleeding (n=11) and/or biochemical signs of sudden biliary obstruction (n=9). The onset of the symptoms occurred after a median of 6 days (range: 1–23). Ultrasound and computed tomography scan missed the diagnosis in, respectively, 4/5 and 2/5 of patients. On arteriography, pseudoaneurysm (6/12) was the most common finding. Transcatheter arterial embolization controlled the bleeding in all cases (12/12) without major complications. Conclusion The delay between the intervention and the clinical presentation and the fact that imaging studies may fail to diagnose hemobilia may mislead the physician. Transcatheter arterial embolization is the treatment of choice for hemobilia. It has proven to be effective and safe and it offers a long-term definitive cure.

Transcatheter Arterial Chemoembolization with Doxorubicin-Eluting Superabsorbent Polymer Microspheres in the Treatment of Hepatocellular Carcinoma: Midterm Follow-up

PURPOSE To investigate prospectively the safety, tolerability, and efficacy of transarterial chemoembolization using superabsorbent polymer (SAP) microspheres loaded with doxorubicin for the treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS During the years 2006-2011, 64 patients underwent 144 transarterial chemoembolization with SAP microspheres procedures. Most of the patients were staged as Barcelona Clinic Liver Cancer class B (65%). The most frequent underlying liver diseases were hepatitis C (35%) and alcoholic liver disease (28%) resulting in Child-Pugh A (73.4%) or Child-Pugh B (17%) liver cirrhosis. Tumor response was assessed using modified Response Evaluation Criteria in Solid Tumors with magnetic resonance (MR) imaging performed 4-6 weeks after each procedure. RESULTS Serious adverse events (n = 9) were ischemic or infectious in nature. Transarterial chemoembolization with SAP microspheres resulted in objective response rates of 67.5%, 44.5%, and 25% after first, second, and third sessions. There were 16 patients (25%) who underwent orthotopic liver transplantation after transarterial chemoembolization with SAP microspheres, of whom 2 experienced recurrent disease. During a median follow-up time of 14 months (range, 2-55 mo), 26 patients (40.5%) died. Median overall and transplant-free survivals were 20.5 months (95% confidence interval, 13.2-27.7) and 18 months (95% confidence interval, 14.2-21.8), respectively. CONCLUSIONS Transarterial chemoembolization with SAP microspheres has an excellent safety profile in cirrhotic patients, even in the presence of advanced liver disease (Child-Pugh B) or advanced stages of HCC. This treatment produced meaningful tumor response rates as assessed by MR imaging.

Large-Bore Nitinol Stents for Malignant Superior Vena Cava Syndrome: Factors Influencing Outcome

OBJECTIVE The purpose of this article is to retrospectively evaluate the technical and clinical outcomes of large-bore nitinol stents for treating malignant superior vena cava syndrome. In addition, we analyzed factors potentially influencing the outcome. MATERIALS AND METHODS Over a 7-year period, 78 consecutive patients presented with superior vena cava syndrome related to primary lung tumor (n=62) or malignant lymphadenopathies (n=16). The factors analyzed were Kishi score at admission, tumor type, and need for an additional balloon-expandable stent. RESULTS Technical success was obtained in all but one patient (99%), who presented with a stent migration immediately after insertion. In 17 patients (22%), an additional balloon-expandable stent was needed for complete expansion of the nitinol stent. For patients with symptomatic malignant lymphadenopathies or primary lung tumor, overall survival rates were 50% (n=8) and 54% (n=34), respectively, at 6 months and 19% (n=3) and 34% (n=21), respectively, at 12 months (p=0.376). There was no difference in survival as a function of the Kishi score (p=0.80) or of the placement of an additional balloon-expandable stent (p=0.35). Finally, reocclusion events were noted in patients both with (n=1) and without (n=7) a balloon-expandable stent. CONCLUSION Large-bore nitinol stents are highly effective for malignant superior vena cava syndrome. The survival rates of patients with caval vein stenosis due to either the primary tumor or secondary enlarged adenopathies were equal. An additional balloon-expandable stent was required in 22% of cases owing to incomplete expansion of the nitinol stent but was not associated with higher thrombosis rate.

Embolization of an Internal Iliac Artery Aneurysm after Image-Guided Direct Puncture

ObjectiveTo evaluate the feasibility, safety, and efficacy of embolization of internal iliac artery aneurysm (IIAA) after percutaneous direct puncture under (cone-beam) computed tomography (CT) guidance.MethodsA retrospective case series of three patients, in whom IIAA not accessible by way of the transarterial route, was reviewed. CT-guided puncture of the IIAA sac was performed in one patient. Two patients underwent puncture of the IIAA under cone-beam CT guidance.ResultsAccess to the IIAA sac was successful in all three patients. In two of the three patients, the posterior and/or anterior division was first embolized using platinum microcoils. The aneurysm sac was embolized with thrombin in one patient and with a mixture of glue and Lipiodol in two patients. No complications were seen. On follow-up CT, no opacification of the aneurysm sac was seen. The volume of one IIAA remained stable at follow-up, and the remaining two IIAAs decreased in size.ConclusionEmbolization of IIAA after direct percutaneous puncture under cone-beam CT/CT-guidance is feasible and safe and results in good short-term outcome.